HESI Comprehensive Exit Practice Exam Questions 2024/2025 | Consisting Of 100 Questions With Verified Answers From Experts

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HESI Comprehensive EXIT Practice Questions

1. The nurse is caring for a client with a cerebrovascular accident (CVA)

who is receiving enteral tube feedings. Which task performed by the UAP

requires immediate intervention by the nurse?

A.Suctions oral secretions from mouth

B.Positions head of bed flat when changing

sheets C.Takes temperature using the axillary

method

D.Keeps head of bed elevated at 30

degrees✅✅✅ Rationale:

Positioning the head of the bed flat when enteral feedings are in

progress puts the client at risk for aspiration (B). The others are all

acceptable tasks performed by the UAP (A, C, and D).

2. When caring for a postsurgical client who has undergone multiple

blood transfusions, which serum laboratory finding is of most concern to

the nurse?

A.Sodium level, 137 mEq/L

B.Potassium level, 5.5

mEq/L

C.Blood urea nitrogen (BUN) level, 18 mg/dL

D.Calcium level, 10

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mEq/L✅✅✅ Rationale:

Multiple blood transfusions are a risk factor for hyperkalemia. A serum

potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The

others are normal findings (A, C, and D).

3. Which vaccination should the nurse administer to a

newborn? A.Hepatitis B

B.Human papilloma virus (HPV)

C.Varicella

D.Meningococcal

vaccine✅✅✅ Rationale:

The hepatitis B vaccination should be given to all newborns before

hospital dis- charge (A). HPV is not recommended until adolescence

(B). Varicella immunization begins at 12 months (C). Meningococcal

vaccine is administered beginning at 2 years (D).

4. The nurse is caring for a client on the medical unit. Which task can

be delegated to unlicensed assistive personnel (UAP)?

A.Assess the need to change a central line dressing.

B.Obtain a fingerstick blood glucose level.

C.Answer a family member's questions about the client's plan of care.

D.Teach the client side effects to report related to the current medication

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regimen.✅

✅✅

Rationale:

Obtaining a fingerstick blood glucose level is a simple treatment and is

an appro- priate skill for UAP to perform (B). (A, C, and D) are skills

that cannot be delegated to UAP.

5. The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s)

should the nurse expect to implement? (Select all that apply.)

A.Administer aspirin with tissue plasminogen activator (t-PA).

B.Complete the National Institute of Health Stroke Scale

(NIHSS).

C.Assess the client for signs of bleeding during and after the infusion.

D.Start t-PA within 6 hours after the onset of stroke symptoms.

E.Initiate multidisciplinary consult for potential

rehabilitation.✅✅✅,C,E Rationale:

Neurologic assessment, including the NIHSS, is indicated for the client

receiving t-PA. This includes close monitoring for bleeding during and

after the infusion; if bleeding or other signs of neurologic impairment

occur, the infusion should be stopped (B, C, and E). Aspirin is

contraindicated with t-PA because it increases the risk for bleeding

(A). The administration of t-PA within 6 hours of symptoms is

concurrent with a diagnosis of a myocardial infarction and within 4.5

hours of symptoms is concurrent for a stroke (D).

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6. When caring for a client in labor, which finding is most important to

report to the primary health care provider?

A.Maternal heart rate, 90 beats/min.

B.Fetal heart rate, 100 beats/min

C.Maternal blood pressure, 140/86 mm Hg

D.Maternal temperature, 100.0°

F✅✅✅ Rationale:

A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress

(B) because the average FHR at term is 140 beats/min and the normal

range is 110 to beats/min

160. The others (A, C, and D) are normal findings for a woman in labor.

7. The nurse is caring for a client with heart failure who develops

respiratory distress and coughs up pink frothy sputum. Which action

should the nurse take first?

A.Draw arterial blood gases.

B.Notify the primary health care provider.

C.Position in a high Fowler's position with the legs down.

D.Obtain a chest X-ray.✅✅✅